Compositions and methods for treating Demodex infestations

ABSTRACT

Compositions containing about 0.6% to about 20% of tea tree oil are described. Some compositions are in the form of solutions, suspensions, spray, lotions, gels, pastes, medicated sticks, balms, cleansers (including shampoos and soaps), creams, or ointments. Also described are compositions and methods for use in treating ocular  Demodex  infestations and related conditions using such compositions.

This application is a divisional application of U.S. application Ser.No. 11/846,961, filed Aug. 29, 2007, which is incorporated herein byreference in its entirety,

BACKGROUND OF THE INVENTION

Demodex mites (of the class Arachnid and order Acarina) are microscopicectoparasites that commonly infest the pilosebaceous unit of the skin.Among a wide range of reported species, at least Demodex folliculorum(D. folliculorum) and Demodex brevis (D. brevis) are found on the humanbody surface. Both Demodex species often coexist and preferentiallygather at the same skin area of the face, cheeks, forehead, nose, andexternal ear tract, where active sebum excretion favors their habitatand breeding. Adult Demodex mites eventually die after a life cycle of14 to 18 days, and their expansion is dependent on successful copulationby adult mites. Copulation takes place in the opening of the hairfollicle (near the skin surface). Afterwards, the gravid female moves tothe sebaceous gland to deposit eggs, which give rise to larvae and thenprotonymphs. A protonymph is brought to the opening of the hair follicleand gives rise to a deutonymph, which crawls onto the skin surface andre-enters a hair follicle to become an adult. Therefore, during a lifecycle, if adult Demodex can successfully copulate and produce the nextgeneration, the extent of infestation will increase in the host.

Demodex infestation is non-existent in healthy children, increases in anage-dependent manner, and is found probably 100% in elderly skin, unlesseradicating measures are taken. The prevalence of Demodex infestation ishigher in unhealthy skin than in normal skin. Overgrowth of these mitesis linked to blepharitis (an inflammation of the eyelids), and otherinflammation-associated conjunctival and corneal abnormalities.Blepharitis occurs as an ulcerous (staph) or nonulcerous (seborrheic)form, or a combination of both. Patients who suffer from blepharitis asa result of an ocular Demodex infestation often present a number ofsymptoms such as foring body sensation, redness and itching.Uncontrolled ocular Demodex infestation in eyelids may causemal-directed lashes (trichiasis), meibomian gland dysfunction leading tolipid tear deficient dry eye, conjunctival inflammation(conjunctivitis), and sight-threatening corneal abnormalities. Thesymptoms can become severe enough that the patient may require surgeryto achieve relief.

Rosacea is a chronic dermatological disease that affects the skin,usually the face, and sometimes the eyes. Inflammatory rosacea causespersistent redness and pink bumps referred to as papules, and pustuleson the skin. Eye inflammation also may occur, with symptoms oftenincluding sensitivity to light, blurred or otherwise impaired vision,redness, dryness, itching, burning, tearing, and the sensation of havinggrit or sand in the eye. Inflammation of the eye is more apparent inadvanced stages of rosacea, where the skin thickens and becomes a deepshade of red. Current treatments include oral antibiotics, e.g.,tetracycline or doxycycline. If infections of the eyelids develop,physicians may recommend scrubbing the eyelids with diluted babyshampoo. Steroid eye drops may be prescribed in the case of severeinfection.

Acne, including acne vulgaris and acne rosacea, is yet another chronicdermatological condition that is difficult to treat. Over-the-counterproducts for treatment of acne, including benzoyl peroxide and aluminiumchlorhydroxide/sulphur can help reduce, but not cure, acne. Prescriptiontreatments, including antibiotics, retinoids, and certain hormone pills,can improve acne, but can have serious adverse effects.

Demodex can also infest mammalian quadrupeds, in particular domesticanimals, especially dogs, causing demodetic mange. The Demodex miteburrows into hair follicles and sebaceous glands of the animal, oftencausing severe dermatitis, infection, and discomfort. Demodetic mange,particularly in dogs, presents a difficult clinical problem forveterinarians, as it can involve the face and the entire body of theanimal in some cases. Existing treatments can be expensive and are notalways effective, with the result that affected animals are sumtimeseuthanized. Mange can also be caused by the burrowing parasitic miteSarcoptes, which causes scabies, and Chorioptes. The Cheyletiella mitecauses a condition known as “walking dandruff.” In cats, notoedric mangeis a burrowing mite infestation that is difficult to treat.

SUMMARY OF THE INVENTION

Compositions are described herein containing about 0.6% to about 20% oftea tree oil. In some embodiments, such compositions are in the form ofsolutions, suspensions, spray, lotions, gels, pastes, medicated sticks,balms, cleansers (including shampoos and soaps), creams, or ointments.In some embodiments, the compositions are in the form of an ointment.Also described herein are compositions and methods for use in treatingocular Demodex infestations and related conditions.

In one aspect are dermatologic or ophthalmic compositions comprisingabout 0.6% to about 20% w/w tea tree oil, about 3.0% to about 15% w/wtea tree oil, about 4% to about 10% w/w tea tree oil, or about 5% teatree oil, and a dermatologically and/or ophthalmically acceptable base.In some embodiments, the dermatologically and/or ophthalmicallyacceptable base is an ointment base. In some embodiments, thecomposition is indicated for the treatment of a Demodex infestation.

In another aspect are dermatologic or ophthalmic compositions for reliefof ocular itching, redness of the eye, soreness of the eye, ocularinflammation, or blurred vision, wherein the compositions comprise about0.6% to about 20% w/w tea tree oil, about 3.0% to about 15% w/w tea treeoil, about 4% to about 10% w/w tea tree oil, or about 5% tea tree oil,and a dermatologically and/or opthalmically acceptable base.

In another aspect are dermatologic or ophthalmic compositions fortreating a Demodex infestation (or for relief of symptoms associatedwith such conditions), where the dermatologic or ophthalmic compositionscomprise about 1% to about 20% terpinen-4-ol, about 0.3% to about 5.6%γ-terpinene, about 0.2% to about 3% 1,8 cineole, or about 0.2% to about2.6% α-terpinene, or any combination thereof, and a dermatologicallyand/or ophthalmically acceptable base (e.g., an ointment base).

In another aspect are dermatologic or ophthalmic compositions for reliefof ocular itching, redness of the eye, soreness of the eye, ocularinflammation, or blurred vision, where the dermatologic or ophthalmiccompositions comprise about 1% to about 20% terpinen-4-ol, about 0.3%)to about 5.6% γ-terpinene, about 0.2% to about 3% 1,8 cineole, or about0.2% to about 2.6% α-terpinene, or any combination thereof, and adermatologically and/or ophthalmically acceptable base (e.g., anointment base).

In another aspect are methods for treating ocular Demodex infestation orDemodex-induced blepharitis (or for relief of symptoms associated withsuch conditions), where the methods include applying an ophthalmiccomposition comprising about 0.2% to about 20% w/w tea tree oil and anophthalmically acceptable base (e.g., an ointment base) to the eyelidarea of a subject in need thereof; massaging the composition onto theeyelid margin and eyelash root areas; and repeating the applying andmassaging steps. In some embodiments, the subject being treated showsimprovement in ocular itching, Demodex count, foreign body sensation,mal-directed lashes, lash falling, dry eye, redness, light-sensitivity,or any combination thereof. In some embodiments, the methods compriseapplying an ophthalmic composition comprising about 5% w/w tea tree oil.In some embodiments, the subject to be treated is refractory to ananti-inflammatory, conventionally anti-microbial antibiotic, or ananti-allergy therapy for ocular Demodex infestation or Demodex-inducedblepharitis. In some embodiments, the methods also include scrubbing theeyelid margin and eyelash with a tea tree oil solution or suspensionbefore or after application of the above-described composition. In someembodiments, the tea tree oil solution is a tea tree oil shampoo.

In a further aspect are methods for treating ocular Demodex infestationor Demodex-induced blepharitis in a subject in need thereof, where themethods include applying an ophthalmic composition comprising about 1%to about 20% terpinen-4-ol, about 0.2% to about 5.6% γ-terpinene, about0.2% to about 3% 1,8 cineole, or about 0.2% to about 2.6% α-terpinene,or any combination thereof, and an ophthalmically acceptable base (e.g.,an ointment base) to the eyelid area; massaging the ophthalmiccomposition onto the eyelid margin and eyelash root areas; and follicle,to reduce Demodex copulation, to reduce Demodex presence, or to reduceDemodex re-infestations. In some embodiments, the subject to be treatedis refractory to an anti-inflammatory, anti-microbial or an anti-allergytherapy for ocular Demodex infestation or Demodex-induced blepharitis.In some embodiments, the methods also include the eyelid margin andeyelash root areas with a tea tree oil solution or suspension, e.g., teatree oil shampoo.

In a further aspect are articles of manufacture, where an article ofmanufacture includes a dispenser; an ointment comprising about 0.6% toabout 20% w/w tea tree oil and a pharmaceutically acceptable ointmentbase; and instructions for use comprising the steps of applying theointment to the affected area, massaging the ointment onto the affectedarea and repeating the applying and massaging steps until sufficient tomigrate Demodex out of the affected area, to reduce Demodex count, or toreduce Demodex re-infestation. In some embodiments, the ointmentcomprises about 5% w/w tea tree oil.

In yet another aspect are methods for Demodex-induced rosacea, acne, andmeibomian gland dysfunction in a subject in need, where the methodincludes applying a dermatologic or ophthalmic composition comprisingabout 0.6% to about 20% w/w tea tree oil and a dermatologically and/orophthalmically acceptable base to the affected area; massaging thecomposition onto the affected area; and repeating the applying andmassaging steps until sufficient to show an improvement in the disorder.In some embodiments, the dermatologically and/or ophthalmicallyacceptable base is an ointment base. In some embodiments, the methodsalso include scrubbing the affected area with a tea tree oil solution orsuspension (e.g., tea tree oil shampoo).

In a further aspect are methods for treating Demodex-induced rosacea,acne, and meibomian gland dysfunction in a patient in need thereof,where the methods include applying a dermatologic or ophthalmiccomposition comprising about 1% to about 20% terpinen-4-ol, about 0.2%to about 5.6% γ-terpinene, about 0.2% to about 3% 1,8 cineole, or about0.2% to about 2.6% α-terpinene, or any combination thereof, and adermatologically and/or ophthalmically acceptable base to the eyelidarea; massaging the composition onto the affected area; and repeatingthe applying and massaging steps until sufficient to show an improvementin the disorder. In some embodiments, the methods further includescrubbing the affected area with a tea tree oil solution or suspension(e.g., tea tree oil shampoo).

In another aspect are methods for treating sarcoptic mange, demodecticmange, chorioptic mange, notoedric mange, or a cheyletiella miteinfestation on a mammal in need thereof, where the methods includeapplying an ointment comprising about 0.6% to about 20% w/w tea tree oiland a pharmaceutically acceptable ointment base to the affected area,and massaging the ointment onto the affected area.

In yet another aspect are methods for treating sarcoptic mange,demodectic mange, chorioptic mange, notoedric mange, or a cheyletiellamite infestation on a mammal in need thereof comprising: applying anointment comprising about 0.6% to about 20% terpinen-4-ol, about 0.2% toabout 5.6% γ-terpinene, about 0.2% to about 3% 1,8 cineole, or about0.2% to about 2.6% α-terpinene, or any combination thereof, and apharmaceutically acceptable ointment base to the affected area, andmassaging the ointment onto the affected area.

INCORPORATION BY REFERENCE

All publications, patents, and patent applications mentioned in thisspecification are herein incorporated by reference to the same extent asif each individual publication, patent, or patent application wasspecifically and individually indicated to be incorporated by reference.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an illustrative bar graph showing ocular itch grading indemodecosis patients before and after treatment with an ointmentcontaining 5% (w/w) tea tree oil ointment.

FIG. 2 is an illustrative bar graph showing the incidence of symptomsamong demodecosis patients before and after treatment with an ointmentcontaining 5% (w/w) tea tree oil ointment.

DETAILED DESCRIPTION OF THE INVENTION

The appended claims particularly point out features set forth herein. Abetter understanding of the features and advantages of the presentdisclosure will be obtained by reference to the following detaileddescription that sets forth illustrative embodiments, in which theprinciples described herein are utilized.

Disclosed herein are demodicidal compositions and methods for their usein treating Demodex infestations (including ocular Demodexinfestations), Demodex-induced blepharitis, rosacea, acne, meibomiangland dysfunction, mange, cheyletiella mite infestations, and relatedconditions.

Demodex infestations are commonly treated with systemic and topicaladministration of parasiticides. For example, ocular Demodex can betreated by performing a daily eyelid margin scrub with diluted shampooalone or in combinations with a mercury oxide ointment, a metronidazolegel, or a pilocarpine gel applied to the base of the eye lashes.Unfortunately, these treatments frequently fail to eradicate thisparasite, and therefore the infestation persists.

Accordingly, described herein is a new method for treating theaforementioned conditions. Without wishing to be bound by theory, it isbelieved that the compositions described herein promote migration ofDemodex mites away from the treated area (e.g., the surface of aneyelid), inhibit reproduction of the mites, kill the mites, preventre-infestation from the surrounding area, or provide a combination ofany of the foregoing effects, which makes them useful for treatingDemodex mite infestations and related conditions.

The compositions and methods described herein can be used to treatconditions that include, but are not limited to, Demodex infestation(e.g., ocular Demodex infestation), Demodex-induced blepharitis,rosacea, acne, meibomian gland dysfunction, chronic conjuctivitis,allergic conjunctivitis, trichiasis, sarcoptic mange, demodectic mange,chorioptic mange, notoedric mange, or a Cheyletiella mite infestation.Ocular Demodex infestations are accompanied by a number of symptomsincluding, e.g., itching, foreign body sensation, lash fallout,mal-directed lashes, redness, light sensitivity, or any combination ofthese symptoms.

Demodex species that can be controlled by the compositions describedherein include, but are not limited to, D. folicularum, D. brevis, D.canis, D. gatoi, D. bovis, D. equi, D. ovis, D. cati, D. phyloides, andD. caprae. A subject to be treated with the compositions and methodsdescribed herein can be any mammal including, e.g., a human, a dog, acat, a horse, a cow, a sheep, or a pig.

Compositions

The agents described herein may be administered topically and can beformulated into a variety of topically administrable compositionscomprising an active ingredient and a dermatologically acceptable baseand/or an ophthalmically acceptable base. Such compositions can beformulated, e.g., as solutions, suspensions, spray, lotions, gels,pastes, medicated sticks, balms, shampoos, creams or ointments. In oneembodiment, the composition is the form of an ointment that can beapplied in or around the eye of a mammal, including a human.

The active ingredients of such compositions can include tea tree oiland/or any combination of ingredients found in tea tree oil (seeherein).

As used herein, “tea tree oil,” i.e., 100% tea tree oil comprises theranges of components listed in Table 1.

TABLE 1 Components of Tea Tree Oil (TTO) ISO 4730 Range Ingredients(%) 1. Terpinen-4-ol >30 2. γ-Terpinene  10-28 3. 1,8 Cineole   0-15 4.α-Terpinene   5-13 5. p-Cymene 0.5-12 6. α-Terpineol 1.5-8 7. δ-CadineneTrace-8 8. Aromadendrene Trace-7 9. Ledene 0.5-6.5 10. α-Pinene   1-611. Terpinolene 1.5-5 12. Limonene 0.5-4 13. Sabinene Trace-3.5 14.Globulol Trace-3 15. Viridiflorol Trace-1.5

As used herein, a “dermatologically acceptable base,” refers to one ormore non-detergent excipients that do not cause irritation,inflammation, pain, or other harm to the skin when applied to the skin.

As used herein, an “ophthalmically acceptable base,” refers to one ormore non-detergent excipients that do not irritate or otherwise harm thesurface of the eye when applied on the eyelid and eyelash area of theeye.

In some embodiments, a composition contains a dermatologically and/orophthalmically acceptable base and about 0.2% to about 20% (w/w) teatree oil, e.g., about 3% to about 15%, about 4% to about 10%), about 5%,or any other percent (w/w) of tea tree oil from about 0.2% to about 20%,e.g., 0.20%, 0.22% 0.30%, 0.40%, 0.50%, 0.60%, 0.80%, 1.0%, 1.2%, 1.4%,1.6%, 1.8%, 2.0%, 2.2%, 2.4%, 2.6%, 2.8%, 3.0%, 3.2%, 3.4%, 3.6%, 3.8%,4.0%, 4.2%, 4.7%, 5.2%, 5.7%, 6.2%, 6.7%, 7.2%, 7.7%, 8.2%, 8.7%, 9.2%,9.5%, 10.0%, 10.5%, 11.2%, 11.5%, 12.0%, 12.4%, 12.9%, 13.3%, 13.5%,13.7%, 14.0%, 14.5%, 15.0%, 15.5%, 16.0%, 16.6%, 17.0%, 17.4%, 18.0%,18.5%, 18.8%, 19.0%, 19.2%, 19.4%, 19.5%, 19.6%, 19.7%, 19.8%, 19.9%, or20% tea tree oil (w/w).

In some embodiments, a composition comprises a dermatologically and/orophthalmically acceptable base and about 1% to about 20% (w/wterpinen-4-ol, e.g., about 3% to about 15%, about 4% to about 10%, about5%, or any other percent (w/w) of terpinen-4-ol falling between about 1%to about 20%, e.g., 1.0%, 1.2%, 1.4%, 1.6%, 1.8%, 2.0%, 2.2%, 2.4%,2.6%, 2.8%, 3.0%, 3.2%, 3.4%, 3.6%, 3.8%, 4.0%, 4.2%, 4.5%, 5.2%, 5.7%,6.2%, 6.7%, 7.4%, 7.7%, 8.2%, 8.5%, 9.2%, 9.5%, 10.0%, 10.5%, 11.2%,11.5%, 12.0%, 12.4%, 12.9%, 13.3%, 13.5%, 13.7%, 14.0%, 14.7%, 15.0%,15.5%, 16.0%, 16.6%, 17.0%, 17.4%, 18.3%, 18.5%, 18.8%, 19.0%, 19.2%,19.4%, 19.5%, 19.6%, 19.7%, 19.8%, 19.9%, or 20% terpinen-4-ol.

In some embodiments, a composition comprises a dermatologically and/orophthalmically acceptable base and about 0.2% to about 9% (w/w)γ-Terpinene, e.g., about 0.4% to about 5.2%, about 0.7% to about 5%,about 0.9% to about 4.4%, about 1.3% to about 4%, about 1.5% to about3.6%, or any other percent (w/w) of terpinen 4-ol from about 0.2% toabout 5.6%, or any other percent (w/w) of γ-Terpinene from about 1% toabout 6%, e.g., 1.2%, 1.4%, 1.6%, 1.8%, 2.0%, 2.2%, 2.4%, 2.6%, 2.8%,3.0%, 3.2%, 3.4%, 3.6%, 3.8%, 4.0%, 4.2%, 4.5%, 5.2%, 5.7% 6.2%, 6.7%,7.4%, 7.7%, 8.2%, or 8.5% γ-Terpinene.

In some embodiments, a composition comprises a dermatologically and/orophthalmically acceptable base and about 0.2% to about 10% (w/w) 1,8cineole, e.g., about 0.4% to about 2.6%, about 0.6%) to about 2.4%, 0.8%to about 2.2%, about 0.9% to about 2.0%, or any other percent (w/w) of1,8 cineole from about 0.2% to about 3%, e.g., 0.20%, 0.22% 0.30%,0.40%, 0.50%, 0.60%, 0.80%, 1.0%, 1.2%, 1.4%, 1.6%, 1.8%, 2.0%, 2.2%,2.4%, 2.6%, 2.8%, 3.0%, 3.2%, 3.4%, 3.6%, 3.8%, 4.0%, 4.2%, 4.7%, 5.2%,5.7%, 6.2%, 6.7%, 7.2%, 7.7%, 8.2%, 8.7%, 9.2%, or 9.5% 1,8 cineole.

In some embodiments, a composition comprises a dermatologically and/orophthalmically acceptable base and about 0.2% to about 4.5% (w/w)α-terpinene, e.g., about 0.3% to about 2.2%, about 0.5%) to about 2.0%,about 0.6% to about 1.8%, or any other percent (w/w) of α-Terpinene fromabout 0.1% to about 4.5%, e.g., 0.20%, 0.22% 0.30%, 0.40%, 0.50%, 0.60%,0.80%, 1.0%, 1.2%, 1.4%, 1.6%, 1.8%, 2.0%, 2.2%, 2.4%, 2.6%, 2.8%, 3.0%,3.2%, 3.4%, 3.6%, 3.8%, 4.0%, 4.2% α-terpinene.

In some embodiments, a composition comprises a pharmaceuticallyacceptable ointment and a combination two or more of about 0.2% to about20% (w/w) terpinen 4-ol, 0.2% to about 5.6% (w/w) γ-Terpinene; about0.2% to about 3% (w/w) 1,8 cineole; and about 0.3% to about 2.6% (w/w)α-terpinene.

In some embodiments, a dermatologically and/or ophthalmically acceptablebase includes a pharmaceutically acceptable ointment base. Examples ofsuitable ointment bases include, but are not limited to oleaginousointment bases such as petrolatum (e.g., liquid petrolatum or whitepetrolatum), plastibase, hard paraffin, white soft paraffin, yellow softparaffin, liquid paraffin, emulsifying wax, microcrystalline wax, whitebees wax, yellow bees wax, carnauba wax, wool wax (wool fat), mineraloil, olive oil, purified lanolin, anhydrous lanolin, and water solubleointment bases such as polyethylene glycol (e.g., polyethylene glycol400 or polyethylene glycol 3350), propylene glycol, polyoxyethylene,polyoxypropylene, or any combinations thereof.

In some embodiments, a dermatologically and/or ophthalmically acceptablebase includes one or more polymers as suspending agents. Useful polymersinclude, but are not limited to, water-soluble polymers such ascellulosic polymers, e.g., hydroxypropyl methylcellulose, andwater-insoluble polymers such as cross-linked carboxyl-containingpolymers. A dermatologically and/or ophthalmically acceptable base canalso include a dermatologically and/or ophthalmically acceptablemucoadhesive polymer, e.g., carboxymethylcellulose, carbomer (acrylicacid polymer), poly(methylmethacrylate), polyacrylamide, polycarbophil,acrylic acid/butyl acrylate copolymer, sodium alginate, or dextran.

In some embodiments, a dermatologically and/or ophthalmically acceptablebase includes one or more viscosity enhancing agents. Examples ofsuitable viscosity enhancing agents include, but are not limited to,methyl cellulose, xanthan gum, gum tragacanth, carboxymethyl cellulose,hydroxypropyl cellulose, hydroxypropylmethyl cellulose,hydroxypropylmethyl cellulose acetate stearate, hydroxypropylmethylcellulose phthalate, carbomer, polyvinyl alcohol, alginates, acacia,chitosans, acacia, corn starch, gelatin, or combinations thereof.

In some embodiments, a dermatologically and/or ophthalmically acceptablebase includes one or more dermatologically and/or ophthalmicallyacceptable pH adjusting agents or buffering agents, including, but notlimited to, acids such as acetic, boric, citric, lactic, phosphoric andhydrochloric acids; bases such as sodium hydroxide, sodium phosphate,sodium borate, sodium citrate, sodium acetate, sodium, lactate andtris-hydroxymethylaminomethane; and buffers such as citrate/dextrose,sodium bicarbonate and ammonium chloride. Such acids, bases and buffersare included in an amount required to maintain pH of the composition ina dermatologically and/or ophthalmically acceptable range.

In some embodiments, a dermatologically and/or ophthalmically acceptablebase includes one or more dermatologically and/or ophthalmicallyacceptable salts in an amount required to bring osmolality of thecomposition into a dermatologically and/or ophthalmically acceptablerange. Such salts include, but are not limited to, those having sodium,potassium or ammonium cations and chloride, citrate, ascorbate, borate,phosphate, bicarbonate, sulfate, thiosulfate or bisulfite anions;specific salts include, e.g., sodium chloride, potassium chloride,sodium thiosulfate, sodium bisulfite, and ammonium sulfate.

In some embodiments, a dermatologically and/or ophthalmically acceptablebase includes one or more dermatologically and/or ophthalmicallyacceptable preservatives to inhibit microbial activity. Suitablepreservatives include, but are not limited to, mercury-containingsubstances such as merfen and thiomersal; stabilized chlorine dioxide;and quaternary ammonium compounds such as benzalkonium chloride,cetyltrimethylammonium bromide and cetylpyridinium chloride.

In further embodiments, a dermatologically and/or ophthalmicallyacceptable base includes one or more dermatologically and/orophthalmically acceptable surfactants to enhance physical stability, orfor other purposes. Suitable nonionic surfactants includepolyoxyethylerie fatty acid glycerides and vegetable oils, e.g.,polyoxyethylene (60) hydrogenated castor oil; and polyoxyethyleriealkylethers and alkylphenyl ethers, e.g., octoxynol 10, octoxynol 40.

In yet other embodiments, a dermatologically and/or ophthalmicallyacceptable base includes one or more antioxidants to enhance chemicalstability where required. Suitable antioxidants include, by way ofexample only, butylated hydroxytoluene (BHT), sodium ascorbate, ascorbicacid, sodium metabisulfite, and tocopherol. In certain embodiments,antioxidants enhance chemical stability where required.

Details on techniques for formulation may be found in the latest editionof Remington's Pharmaceutical Sciences (Maack Publishing Co., Easton,Pa.).

Methods for determining the presence and amounts of specific chemicalcomponents and byproducts thereof (e.g., degradation products) in any ofthe compositions described herein include, for example, an assay methodcan be based on the industry standard produced by the AustralianStandard Method as 2782-1997, “Oil of Melaleuca, terpinen-4-ol type(Tree Tea Oil)” and following GLP set using Gas Chromatography (GC-FID)and Gas-chromatography mass spectrometry. See, e.g., Brophy et al.(1989), J Agric Food Chem, 37:1330-1335; and Mondello et al. (2006), BMCInfect Dis, 6:158.

Toxicity and therapeutic efficacy of such compositions can be determinedby standard pharmaceutical procedures in cell cultures or experimentalanimals, for example, in accordance with the ISO 10993-1 standard fortoxicology testing and in accordance with GLP (Good Laboratory Practice)regulations.

For example, cell culture assays can be used to assess thebiocompatibility of a material through the use of isolated cells invitro. These techniques are useful in evaluating the toxicity orirritancy potential of materials and chemicals and they provide anexcellent way to screen material prior to in vivo tests. Specifically,the MEM elution assay can be performed on a series of dilutions of thecompounds described herein. Each compound dilution is added to amonolayer of L-929 cells and then incubated. Afterwards, cells areexamined microscopically for malformation, degeneration and lysis, andthe test compound is scored for its cytopathic effect.

In another example, an ocular irritation test is designed to determinethe ocular irritation and toxicity of solutions for up to 72 hours inrabbits' eyes. Generally, 3 rabbits with clinically normal eyes are usedin a study. Rabbits' eyes are examined daily and scored using the Draizesystem. Before treatment and at 1, 24, 48 and 72 hours, the eyes of eachrabbit are also examined with an ophthalmoscope and scored for ocularirritation using the McDonald-Shadduck method (slit-lamp and fluoresceinstain).

Methods of Treatment

The compositions described herein can be used for the manufacture of amedicament for treating any of the foregoing conditions (e.g., an ocularDemodex infestation, rosacea, meibomian gland dysfunction, demodecticmange, etc.).

In some embodiments, where the condition to be treated is an ocularDemodex infestation, Demodex-induced blepharitis, or a relatedcondition, the compositions described herein (e.g., a dermatogically orophthalmically acceptable ointment) are administered (e.g., selfadministered) topically by gentle application to a subject's skin, or,if treating an ocular condition, the eyelid margin, skin, and eyelashroots, followed by massaging of the eyelid margin and skin from one endto the other, and repeating the applying and massaging steps untilsufficient to migrate Demodex out of the lash follicle, to reduceDemodex copulation, to reduce Demodex presence, or to reduce Demodexre-infestation. In some embodiments, excess composition is left on theeyelid area is left on until the next treatment. In other embodiments,excess composition is wiped or washed away after massaging. In someembodiments, the eyelid margin, skin, and eyelash root areas arescrubbed with a tea tree oil solution or suspension prior to applicationof one of the ophthalmically acceptable compositions described herein.In other embodiments, the tea tree oil solution or suspension is used toscrub after one of the ophthalmically acceptable compositions describedherein has been applied and massaged onto the eyelid margin, skin,eyelash root areas. The tea tree oil solution or suspension used forscrubbing can have any concentration of tea tree oil from about 2% to100% tea tree oil, e.g., about 2%, 3%, 4%, 4.5%, 5%, 6%, 7%, 9.5%, 12%,14.5% 17%, 19.5%, 22%, 24.5%, 27%, 29.5%, 32%, 34.5%, 37%, 39.5%, 42%,44.5%, 47%, 49.5%, 52%, 54.5%, 57%, 60%, 62%, 64.5%, 67%, 69.5%, 72%,74.5%, 77%, 79.5%, 82%, 84.5%, 87%, 89.5%, 92%, 94.5%, 97%, or 99.5% teatree oil. In some embodiments, the tea tree oil solution is a tea treeoil shampoo, which is commercially available, e.g., Kato Sales, Inc.(Altamonte Springs, Fla., USA).

A number of endpoints can be used to evaluate the therapeutic efficacyof the methods described herein. For example, a reduction in one or moreof ocular itching, Demodex count (i.e., Demodex presence), foreign bodysensation, eyelash fallout, mal-directed lashes, dry eye, lightsensitivity or eye redness are indicative of a successful treatment.Thus, in some embodiments, applying and massaging of an ointment to theeyelid is repeated until one or more of the just-described endpoints areattained.

In an exemplary embodiment, an ointment formulation is generated bymixing tea tree oil from Essential Oil Company, (Portland, Oreg., USA)with Vaseline to a final concentration (w/w) of 5% tea tree oil.Application and massage of 5% tea tree oil ointment is performed twice aday (e.g., once before noon and once before bedtime) for five minuteseach, for a total treatment period of about four weeks.

The compositions containing the compound(s) described herein can beadministered for prophylactic and/or therapeutic treatments. Intherapeutic applications, the compositions are administered to a patientalready suffering from an ocular Demodex infestation, Demodex-inducedblepharitis, or a related condition, in an amount and duration ofapplication time sufficient to cure or at least partially arrest thesymptoms of the disease or condition. Amounts effective for this usewill depend on the severity and course of the disease or condition,previous therapy, the patient's health status, weight, and response tothe drugs, and/or the judgment of a treating physician.

In prophylactic applications, compositions containing the compoundsdescribed herein are administered to a patient susceptible to orotherwise at risk of an ocular Demodex infestation, Demodex-inducedblepharitis, or a related condition.

In another embodiment, where the condition to be treated is rosacea,acne, meibomian gland dysfunction, or related disorder, the compositionsdescribed herein are ointment formulations administered (e.g., selfadministered) topically by gentle application to a subject's affectedarea (e.g., face, neck, or eyelid), followed by massaging of theaffected area from one end to the other, and repeating the applying andmassaging steps until sufficient to show an improvement in the disorder.In some embodiments, excess ointment left on the affected area is lefton until the next treatment. In other embodiments, excess ointment iswiped away after massaging. In some embodiments, after excess ointmentis wiped away, the affected area is scrubbed with any of the foregoingtea tree oil solutions or suspensions (e.g., a tea tree oil shampoo).

In another embodiment, where the condition to be treated is sarcopticmange, demodectic mange, chorioptic mange, notoedric mange, orcheyletiella mite infestation on a mammal, the compositions describedherein are ointment formulations administered topically to the mammal inneed by gentle application to the mammal's affected area (e.g. head orentire body), followed by massaging of the affected area from one end tothe other, and repeating the applying and massaging steps untilsufficient to show an improvement in the disorder.

Once improvement of the patient's conditions has occurred based on anevaluation of one or more of the symptoms described herein, amaintenance dose of the composition is administered if necessary.Subsequently, the dosage or the frequency of administration, or both,can be reduced, as a function of the symptoms, to a level at which theimproved condition is retained. Patients can, however, requireintermittent treatment on a long-term basis upon any recurrence ofsymptoms.

The pharmaceutical composition described herein may be in unit dosageforms suitable for single administration of precise dosages. In unitdosage form, the formulation is divided into unit doses containingappropriate quantities of one or more compound. The unit dosage may bein the form of a package containing discrete quantities of theformulation.

Combination Treatments

Compositions described herein can also be used in combination with othertherapeutic reagents that are selected for their therapeutic value forthe condition to be treated. In general, the compositions describedherein and, in embodiments where combinational therapy is employed,other agents do not have to be administered in the same pharmaceuticalcomposition, and may, because of different physical and chemicalcharacteristics, have to be administered by different routes.

In certain instances, it may be appropriate to administer at least onecomposition described herein in combination with another therapeuticagent. By way of example only, if one of the side effects experienced bya patient upon receiving one of the compounds described herein is skinirritation, then it may be appropriate to administer ananti-inflammatory agent in combination with the initial therapeuticagent. Or, by way of example only, the therapeutic effectiveness of oneof the compounds described herein may be enhanced by administration ofan adjuvant (i.e., by itself the adjuvant may have minimal therapeuticbenefit, but in combination with another therapeutic agent, the overalltherapeutic benefit to the patient is enhanced). Or, by way of exampleonly, the benefit experienced by a patient may be increased byadministering one of the compounds described herein with anothertherapeutic agent (which also includes a therapeutic regimen) that alsohas therapeutic benefit. In any case, regardless of the disease,disorder or condition being treated, the overall benefit experienced bythe patient may simply be additive of the two therapeutic agents or thepatient may experience a synergistic benefit.

The particular choice of compounds used will depend upon the conditionof the patient and the appropriate treatment protocol. The compounds maybe administered concurrently (e.g., simultaneously, essentiallysimultaneously or within the same treatment protocol) or sequentially,depending upon the nature of the disease, disorder, or condition, thecondition of the patient, and the actual choice of compounds used.

Therapeutically-effective dosages can vary when the drugs are used intreatment combinations, and methods such as (by way of example only)metronomic dosing, i.e., providing more frequent, lower doses in orderto minimize toxic side effects, can be used to determine such doses.Combination treatment further includes periodic treatments that startand stop at various times to assist with the clinical management of thepatient.

For combination therapies described herein, dosages of theco-administered compounds will of course vary depending on the type ofco-drug employed, on the specific drug employed, on the disease orcondition being treated and so forth. In addition, when co-administeredwith one or more other agents, the compound provided herein may beadministered either simultaneously with the agent(s), or sequentially.

In any case, the multiple therapeutic agents (one of which is acomposition described herein) may be administered in any order or evensimultaneously. If simultaneously, the multiple therapeutic agents maybe provided in a single, unified form, or in multiple forms (by way ofexample only, either as a single ointment or as an ointment and a pill).One of the therapeutic agents may be given in multiple doses, or bothmay be given as multiple doses. If not simultaneous, the timing betweenthe multiple doses may vary from more than fifteen minutes to less thanfour weeks. In addition, the combination methods, compositions andformulations are not to be limited to the use of only two agents; theuse of multiple therapeutic combinations are also envisioned.

The dosage regimen to treat, prevent, or ameliorate the condition(s) forwhich relief is sought, can be modified in accordance with a variety offactors. These factors include the disorder from which the subjectsuffers, as well as the age, weight, sex, diet, and medical condition ofthe subject. Thus, the dosage regimen actually employed can vary widelyand therefore can deviate from the dosage regimens set forth herein.

The pharmaceutical agents which make up the combination therapydisclosed herein may be a combined dosage form or in separate dosageforms intended for substantially simultaneous administration. Thepharmaceutical agents that make up the combination therapy may also beadministered sequentially, with either therapeutic compound beingadministered by a regimen calling for two-step administration. Thetwo-step administration regimen may call for sequential administrationof the active agents or spaced-apart administration of the separateactive agents.

Exemplary Agents for Use in Combination Therapy: Agents for TreatingInflammation

Where the subject is suffering from or at risk of suffering from a skininflammation, an acaricidal composition can be used in with one or moreof the following therapeutic agents in any combination: glucocorticoids(e.g., prednisone, cortisone acetate, prednisolone, methylprednisolone,dexamethasone, betamethasone, triamcinolone, beclometasone,fludrocortisone acetate, deoxycorticosterone acetate, aldosterone),non-steroidal anti-inflammatory drugs (e.g., salicylates, arylalkanoicacids, 2-arylpropionic acids, N-arylanthranilic acids, oxicams, coxibs,or sulphonanilides), Cox-2-specific inhibitors (e.g., valdecoxib,celecoxib, or rofecoxib), leflunomide, gold thioglucose, goldthiomalate, aurofin, sulfasalazine, hydroxychloroquinine, minocycline,TNF-α binding proteins (e.g., infliximab, etanercept, or adalimumab),abatacept, anakinra, interferon-β, interferon-γ, interleukin-2, allergyvaccines, antihistamines, antileukotrienes, beta-agonists, theophylline,or anticholinergics; antibiotics; tarcolimus, or retinoids.

Articles of Manufacture

For use in the applications described herein, kits and articles ofmanufacture are also described herein. The terms “kit” and “article ofmanufacture” are used as synonyms. Such kits can include a carrier,package, or container that is compartmentalized to receive one or morecontainers such as vials, tubes, and the like, each of the container(s)including one of the separate elements to be used in a method describedherein. Preferably, containers (e.g., vials) containing a compositiondescribed herein are light-proof have a tight seal. For example, thecontainer(s) can include one of the dermatologically or opthalmicallyacceptable compositions described herein, i.e., a dermatologically oropthalmically acceptable composition comprising 0.6 to 20% w/w tea treeoil. In an exemplary embodiment, the containers contain an ointmentcomprising about 5% w/w tea tree oil and a pharmaceutically acceptableointment base, as disclosed herein. Suitable containers include, forexample, bottles, vials, syringes, and test tubes. The containers can beformed from a variety of materials such as glass or plastic. Preferably,the container protects against certain wavelengths of light andprolonged high temperature, and/or the ingress of air. Preferably thecontainer is a sealed, light-proof container.

The articles of manufacture provided herein contain packaging materials.Packaging materials for use in packaging pharmaceutical productsinclude, by way of example only U.S. Pat. Nos. 5,323,907, 5,052,558 and5,033,252. Examples of pharmaceutical packaging materials include, butare not limited to, blister packs, bottles, tubes, pumps, bags, vials,light-tight sealed containers, syringes, bottles, and any packagingmaterial suitable for a selected formulation and intended mode ofadministration and treatment. A wide array of topical formulations ofthe compounds and compositions provided herein are contemplated as are avariety of treatments for any of the diseases, disorders, or conditionsassociated with the acarinal species described herein.

Such kits optionally comprise a compound with an identifying descriptionor label or instructions relating to its use in the methods describedherein. For example, the kit may include instructions for use comprisingthe steps of applying the ointment to the affected area, massaging theointment onto the affected area and repeating the applying and massagingsteps until sufficient to migrate Demodex out of the affected area, toreduce Demodex count, or to reduce Demodex re-infestation.

A kit may include one or more additional containers, each with one ormore of various materials desirable from a commercial and userstandpoint for use of the compositions for treating Demodex describedherein. Non-limiting examples of such materials include, but not limitedto, buffers, diluents, carrier, package, container, vial and/or tubelabels listing contents and/or instructions for use, and package insertswith instructions for use. A set of instructions will also typically beincluded.

A label can be on or associated with the container. A label can be on acontainer when letters, numbers or other characters forming the labelare attached, molded or etched into the container itself; a label can beassociated with a container when it is present within a receptacle orcarrier that also holds the container, e.g., as a package insert. Alabel can be used to indicate that the contents are to be used for aspecific therapeutic application. The label can also indicate directionsfor use of the contents, such as in the methods described herein.

In certain embodiments, the pharmaceutical compositions can be presentedin a pack or dispenser device which can contain one or more unit dosageforms containing a compound provided herein. The pack can for examplecontain metal or plastic foil, such as a blister pack. The pack ordispenser device can be accompanied by instructions for administration.The pack or dispenser can also be accompanied with a notice associatedwith the container in form prescribed by a governmental agencyregulating the manufacture, use, or sale of pharmaceuticals, whichnotice is reflective of approval by the agency of the form of the drugfor human or veterinary administration. Such notice, for example, can bethe labeling approved by the U.S. Food and Drug Administration forprescription drugs, or the approved product insert. Compositionscontaining a compound provided herein formulated in a compatiblepharmaceutical carrier can also be prepared, placed in an appropriatecontainer, and labeled for treatment of an indicated condition.

EXAMPLES

The following specific examples are to be construed as merelyillustrative, and not limitative of the remainder of the disclosure inany way whatsoever. Without further elaboration, it is believed that oneskilled in the art can, based on the description herein, utilize thepresent invention to its fullest extent. All publications cited hereinare hereby incorporated by reference in their entirety. Referencethereto evidences the availability and public dissemination of suchinformation.

Example 1 5% Tea Tree Oil (TTO) Topical Formulation

TTO purchased from Essential Oil Company (Portland, Oreg., USA) wasmixed with Vaseline (BaiHe Pharmacy, Quanzhou, China) to 5% (W/W) TeaTree Oil Ointment (TTOO) in a sterile hood to obtain a 5% TTO topicalformulation for treatment of, e.g., an ocular Demodex infestation.

Example 2 Treatment of Ocular Demedecosis with Daily Massage of a 5% TeaTree Oil Ointment (TTOO)

The study was performed at the Second-affiliated Hospital of FujianMedical University, China, with an approval from the InstitutionalEthics Committee. A written informed consent was obtained from everypatient. A total of 24 patients were enrolled with the complaints of eyeitching and other symptoms and carried a diagnosis of either chronicconjunctivitis or allergic conjunctivitis despite prior treatments withtopical antibiotics (Levofloxacin, Tobramycin, Ofloxacin), steroids(Dexamethasone, Prednisolone), and artificial tears. They were confirmedto have ocular Demodex based on a modified Demodex microscopy assay asdescribed in, e.g., Gao et al. (2005), Invest Opthal Vis Sci,46(9):3089-3094. During the first (baseline) examination, patientsymptoms including itching were recorded as 0 (none), 1 (mild andoccasional without disturbing daily activities), 2 (moderate andrequiring the need of rubbing the eye or using eye drops), and 3(severe, more constant, and disturbing daily activities even with theapplication of the eye drops). Symptoms were recorded before and 4 and 8weeks after treatment.

Patients performed the following self-treatment procedure at home: afterwashing the face and lids with baby shampoo or soap and rinsing withwarm water, a small amount of 5% tea tree oil ointment was smeared ontoboth middle fingers. With the eyes closed, both middle fingers applied agentle pressure applied on the lid margin and lash roots while massagingthe lid margin from one end to the other, which counted as one stroke. Atotal of 120 back and forth strokes for 5 minutes were applied, leavingin the end the residual 5% tea tree oil ointment without washing beforethe next treatment. The very first treatment was carried out in theoffice under doctor's instruction while the remaining treatments wereperformed at the home, twice a day before noon nap and at night beforegoing to bed. Such a treatment was practiced for 4 weeks, during whichtime the patient was seen once a week, and 4 weeks later. In addition,the patient was also instructed to cease using facial cosmetics, and towash the hair, the face, nostrils, the external ear and the neck withsoa daily. No other topical medication was used during the tea tree oilointment treatment.

The data were reported as means±SD and analyzed by MicroSoft Excel™(MicroSoft, Redmont Wash.). The data between groups were evaluated bytwo-tailed t test, where P<0.05 was considered statisticallysignificant.

These 24 patients included 10 males and 14 females with a mean age of37.2±15.6 years. Before treatment, they all complained of differentdegrees of itching graded as 1 (n=6), 2 (n=14), and 3 (n=4) for a periodranging from 2 weeks to 2 years (FIG. 1). Other complaints includedforeign body sensation (n=14), lash falling (n=12), dry eye (n=10), andredness (n=6) (FIG. 2). They had also consulted with multipleophthalmologists for the aforementioned ocular irritation, beendiagnosed as chronic conjunctivitis (n=20) or allergic conjunctivitis(n=4), and treated with topical antibiotics (Levofloxacin, Tobramycin,Ofloxacin et.al), steroids (Dexamethasone, Prednisolone), anyanti-allergy (histamine) medication, and/or artificial tears. Routineeye examination disclosed diffuse (n=4) and sporadic (n=11) cylindricaldandruff in their eyelashes. However, mild injection of blood vesselswas noted in the bulbar conjunctiva of 6 patients, and in the lid marginof 4 patients, but not in the remaining majority. We detected Demodexmites in all patients: the Demodex counts per 8removed lashes were2.3±1.5, 2.8±2.1 and 3.1±2.1 for patients with Grade 1, 2 and 3itchiness, respectively (each P>0.05 between groups).

After 4 weeks of treatment by daily home lid massage with 5% tea treeoil ointment, lashes became clean in all except for 4 patients, whichstill had sporadic CD at lashes. The Demodex count dropped to zero in 19patients (79%), and to 0.3±0.2 in the remaining 5 patients, collectivelyresulting in a significant reduction of the Demodex count (P=0.002). Atthe end of 8 weeks, the Demodex count remained zero in 15 patients. Thecomplaint of ocular itching was also dramatically relieved, resulting inGrade 0 (n=16), 1 (n=5), 2 (n=1), and 3 (n=0) (FIG. 1, P<0.001). Othercomplaints also showed different degrees of relief after treatment,e.g., foreign body sensation (n=3, P=0.002) and lash falling (n=2,P=0.003), but not that of dryness (n=7, P=0.82) and redness (n=1, P=0.1)(FIG. 2). Overall, all patients felt that there was a considerably lessweight in lids after the tea tree oil ointment treatment and did notreport any irritation caused by the treatment.

Based on these results, we concluded that daily, at home, lid massagewith 5% tea tree oil ointment resulted in a dramatic relief of itchingand reduction of Demodex counts within one life cycle without causingany side effects. Thus, daily 5% tea tree oil ointment lid massage waseffective for treatment of ocular demedecosis.

Example 3 Acaricidal Activity of Individual Tea Tree Oil Components

Each of the following individual tea tree oil ingredients are tested foracaricidal activity at a range of concentrations serially diluted from0.5% to 30% in an in vitro Demodex killing assay as described below:Terpinen-4-ol, γ-Terpinene, α-Terpinene, α-Terpineol, Limonene,Sabinene, Aromadendrene, Ledene, α-Pinene, Terpinolene, δ-Cadinene,Viridiflorol, and Globulol.

For each assay, 50% tea tree oil is used as a positive control foracaridal activity, and 100%) mineral oil is used as the negativecontrol. The Demodex killing efficiency is measured by the survival timein minutes, reported as mean±SD (n=at least 5 adult mites), and comparedamong these ingredients by two-tailed t test, where p<0.05 is consideredstatistically significant.

Eyelashes with cylindrical dandruff are removed and examined undermagnification to determine the presence of Demodex as previouslyreported in Gao et al., Invest Opthalmol Vis Sci (2005) 46:3089-94. Ifthe epilated lash is found to contain live Demodex, solutions containingdifferent tea tree oil ingredients will be added. If the epilated lashcontains cylindrical dandruff, one drop of fluorescein solution made bywetting a fluorescein strip (FUL-GLO, Akron, Inc., Buffalo Grove, Ill.,USA) with one drop of 0.9% NaCl solution will be added to reveal anyembedded mites, according to Kheirkhah et al., Cornea 26:697-700 (2007).Since Demodex is more susceptible to acaricidal agents at an earlierstage of life, only test adult Demodex are tested as a more robust indexof acaricidal activity. The mites are considered to be adult if theyhave 4 pairs of well-developed legs and stumpy body. The movement of thebody and legs is continuously observed for 150 minutes post-addition ofone of the foregoing test compounds at a particular concentration. Asdescribed in methods by Gao et al, Br J Ophthalmol 89:1468-1473 (2005),the survival time (ST) is defined as from the time when the solution isadded to the time when the movement ceases. ST values of 150 minutes orgreater indicate a lack of acaricidal activity, as shown in Gao et al.(2005), Br J Opthamol, 89:1468-1473.

Example 4 Clinical Studies

All clinical studies follow the Tenets of Helsinki Declaration of HumanStudies and are conducted after the protocol/consent form has beenapproved by the Institutional Review Board.

The clinical studies enroll patients of either gender, ages≧21, andethnic minorities compatible with the community population. We excludechildren because Demodex infestation is uncommon in children, i.e.,under the age of 18 years old. Furthermore, there is a recent report ofperpubertal gynecomastia (enlargement of the breast) developed in threechildren with ages ranging from 4 to 10 after using over-the-counterpersonal care products containing lavender oil (all three cases) and teatree oil (one case). Because in vitro studies also reveal that bothlavender oil and tea tree oil containing ingredients that exertestrogenic and anti-androgenic activities, hence potentially elicitingendocrine-disrupting effects, we would also like to exclude those femaleadults with malignancies (such as breast cancers) that could be worsenedby exposure to such activities. Furthermore, patients that have ahistory of a known fragrance allergy are also excluded.

The inclusion criteria are the presence of cylindrical dandruff duringthe external examination and microscopic confirmation of ocular Demodex.Briefly, at the slit lamp examination, two lashes with cylindricaldandruff are removed by fine forceps from each lid, and separatelyplaced on a glass slide. Thus a total of 8 lashes on 4 slides areepilated, and covered by a coverslip. All lashes are examined under themicroscope, and lashes with cylindrical dandruff are added with a dropof saline containing 0.5% fluorescein to dissolve the cylindricaldandruff. Under the microscope, the stage and type of Demodex mites isrecorded and the number of Demodex is counted and the total number ofmites in 8 lashes is registered as the Demodex count for that patient atthat time.

All patients that meet the inclusion and exclusion criteria are enrolledfrom the Ocular Surface Center (Miami, Fla.), where patients withcomplicated and difficult ocular surface diseases are seen. All enrolledpatients do not use any topical or systemic anti-inflammatory andanti-microbial medications during the study.

Before study and treatment, all patients receive routine history takingincluding grading of symptoms based on the scale provided in OcularSurface Disease Index (OSDI). OSDI screens irritating symptoms of lightsensitivity, gritty sensation, pain or soreness, blurred vision and poorvision (Subtotal A), and whether these symptoms manifest upon thefollowing four activities including reading, driving at night, usingcomputer, or watching TV (Subtotal B) and in the following threeexternal environment such as windy condition, low humidity and airconditioner (Subtotal C). For each of the above twelve items, a score of4 is assigned if the occurrence is “all the time,” a score of 3 if theoccurrence is “most of the time,” a score of 2 if the occurrence is“half of the time”, a score of 1 if the occurence is “some of the time,”and a score of 0 if the occurrence is “none or not applicable.”Therefore, the highest total score is 48, and the lowest is 0.

All patients also receive external examination and photography todetermine the extent of cylindrical dandruff in the upper eyelid,defined as “diffuse” (i.e., cylindrical dandruff found in more than 10lashes) or “sporadic” (less than 10 lashes), and the Demodex samplingand counting according to the modified method (above). Patients withinitial high Demodex counts, defined herein as having 10 mites/8 lashes,are less apt to be eradicated than those with initial low Demodexcounts, defined as having ≦10 mites/8 lashes. Therefore, patients arerandomized to either Study Group or Control Group using pre-assignedblocks to stratify this important variable.

All enrolled patients are evaluated weekly for the first month, forgrading of symptoms and external examination and photography. At the endof the first month, the Demodex count is repeated. The same treatmentregimen and examination is repeated for the second month. At the end ofthe second month, a third Demodex count is taken, and treatment isdiscontinued for one more month, when the final evaluation and the finalDemodex count are repeated at the end of the third month.

To perform the lid scrub, in the office, after a drop of 0.5%proparacaine, a cotton applicator wetted in 50% tea tree oil in mineraloil is used to scrub the lash roots from one end to the other, countedas one stroke. A total of 6 strokes are applied to each lid. A drycotton applicator is then used to remove excess tea tree oil from thelid margin. After 5 minutes, the second lid scrub is performed in thesame manner. After another 5 minutes, the third lid scrub is applied.Eye irritation, if any, is graded using OSDI for each eye, and the eyeis rinsed with non-preserved saline. At home, the patient mixes 0.5 mlof tea tree shampoo with tap water in both middle fingers. With eyesclosed, the lids are massaged back and forth with a medium pressure for3 minutes. The skin is then rinsed with clean water and dried with aface towel. Such home lid scrub is practiced twice daily.

To perform the lid massage, after washing the face and lids with soapand rinsing with warm water, a small amount of 5% tea tree oil ointmentis smeared onto both middle fingers. With eyes closed, both middlefingers apply a gentle pressure on the lid margin and lash roots andmassage the lid margin from one end to the other, each counting as onestroke, for a total of 120 back and forth strokes for 5 minutes. Theremaining ointment is either washed away with a face cloth or left inthe end without washing before the next treatment. The very firsttreatment is carried out in the office under the doctor'sinstruction/supervision while the remaining treatments are performed athome twice a day.

All patients are also instructed to cease using facial cosmetics, and towash the hair, the face, nostrils, the external ear and the neck withsoap daily. Bedding and pillow cases are washed with hot water and driedin a heated dryer immediately after the first office scrub, and once aweek thereafter.

The safety outcome, defined by the occurrence (rate) of eye irritationnoted after each treatment will be compared between Study Group andControl Group using Fisher's exact (X²) test, where p<0.05 is consideredstatistically significant. The initial efficacy outcome is measured bythe extent of reduction of the symptoms measured by OSDI scores, and ofthe Demodex count; both are measured as means±SD. They are comparedwithin the group by comparing the final value to the baseline valueusing two-tailed t test, where p<0.05 is considered statisticallysignificant. The final efficacy outcome is measured as the percentage(rate) of total eradication, which is registered in that patient if theDemodex count reaches zero for two consecutive visits, each separated 4weeks apart. The success rate of achieving total eradication isdetermined in each group and compared between the two groups usingFisher's exact (X²) test, where p<0.05 is considered statisticallysignificant.

Aim 1: To determine whether the weekly office lid massage with a teatree oil ointment by the patient is equivalent to the weekly office lidscrub with 50% tea tree oil solution by the doctor in reducing ocularDemodex counts but free of ocular irritation if both regimens arefollowed by the same daily home lid scrub with tea tree shampoo.

A pilot study in a total of 15 patients is performed using threedifferent concentrations of tea tree oil ointments (n=5 in each groupfor these three different concentrations). Each patient performs officelid massage under the doctor's instruction/supervision using one ofthese three tea tree oil ointments in the doctor's office. Theirritating symptoms, if noted after massage, will be graded by OSDIscores and compared to those recorded before the massage. The highestconcentration of tea tree oil ointment that does not cause irritation inall 5 patients is used for the remaining study.

A total of 30 patients, meeting inclusion and exclusion criteria, arerandomized to either the Control Group (n=15) to receive weekly officelid scrub with 50% tea tree oil solution performed by the doctor or theStudy Group (n=15) to receive weekly office lid massage with a tea treeoil ointment performed by the patient. Afterwards, all patients ineither group perform home lid scrub with tea tree shampoo, twice a day.All patients undergo follow up visits and examinations as describedabove, and the outcome measures are determined and compared at the endof the study within the group and between groups.

Aim 2: To determine whether daily lid massage by the patient at home ismore effective than weekly lid massage by the patient in the office witha tea tree oil ointment, which is followed by daily home lid scrub withtea tree shampoo, in reducing ocular Demodex counts.

A total of 30 patients meeting inclusion and exclusion criteria arerandomized into either the Study Group or the Control Group (n=15 each).The Study Group receives daily lid massage with tea tree oil ointment,twice a day, at home, with each followed by washing the residualointment off from the surrounding lid skin by a face cloth (to reducethe prolonged effect caused by residual tea tree oil ointment). TheControl Group is either the same as the Control Group of Aim 1 using thereported Lid Scrub Regimen or the Study Group of Aim 1. All patientsundergo follow up visits and examinations as described above, and theoutcome measures are determined and compared at the end of the studywithin the group and between groups.

Aim 3: To determine whether daily lid massage with a tea tree oilointment by the patient at home without washing it off between massagesis more effective in eradicating ocular Demodex infestation bypreventing mite re-infestation.

A total of 40 patients meeting inclusion and exclusion criteria arerandomized into either the Study Group or the Control Group (n=20 each).Both Groups will receive the same daily lid massage with tea tree oilointment, twice a day, as described in Aim 2. The remaining ointmentwill be washed away by tap water followed by wiping with a face towel inthe Control group, but will be left on the lid skin around the eye inthe Study Group. All patients undergo follow up visits and examinationsas described above, and the outcome measures are determined and comparedat the end of the study within the group and between groups.

It is understood that the examples and embodiments described herein arefor illustrative purposes only and that various modifications or changesin light thereof will be suggested to persons skilled in the art and areto be included within the spirit and purview of this application andscope of the appended claims.

What is claimed is:
 1. A method of treating an ocular Demodexinfestation or Demodex-induced blepharitis in an individual in needthereof, comprising administering to the individual atherapeutically-effective amount of a composition consisting essentiallyof: about 1% up to, but not including, about 20% w/w of terpinen-4-ol asan active agent, provided that the composition does not include tea treeoil; and at least one ophthalmically acceptable excipient.